Form GST APL - 01
[See rule 108(1)]

Appeal to Appellate Authority

1. GSTIN/ Temporary ID/UIN -
2. Legal name of the appellant -
3. Trade name, if any -
4. Address -
5. Order no. -                                                                                     Order date -
6. Designation and address of the officer passing the order appealed against -
7. Date of communication of the order appealed against -
8. Name of the authorised representative -
9. Details of the case under dispute -

(i) Brief issue of the case under dispute -

(ii) Description and classification of goods/ services in dispute-

(iii) Period of dispute-

(iv) Amount under dispute:

Description Central tax State/ UT tax Integrated tax Cess
a) Tax/ Cess        
b) Interest        
c) Penalty        
d) Fees        
e) Other charges        

(v) Market value of seized goods

10. Whether the appellant wishes to be heard in person - Yes / No

11. Statement of facts:-

12. Grounds of appeal:-

13. Prayer:-

14. Amount of demand created, admitted and disputed

Particulars of demand/ refund Particulars Central tax State/ UT tax Integrated tax Cess Total amount

Amount of demand created (A)

 a) Tax/ Cess         < total > < total >
b) Interest < total >
c) Penalty < total >
d) Fees
e) Other charges < total >
< total >
Amount of demand admitted (B) a) Tax/ Cess         < total > < total >

 
b) Interest < total >
c) Penalty < total >
d) Fees < total >
e) Other charges < total >
Amount of demand disputed (C) a) Tax/ Cess         < total > < total >
b) Interest < total >
c) Penalty < total >
d) Fees < total >
e) Other charges < total >

15. Details of payment of admitted amount and pre-deposit:-

    (a) Details of payment required

Particulars   Central tax State/ UT tax Integrated tax Cess Total amount
 

(a) Admitted amount

Tax/ Cess         < total > < total >
Interest < total >
Penalty < total >
Fees < total >
Other charges < total >
 

(b) Pre- deposit (10% of disputed tax /cess but not exceeding Rs. 20 crore each in respect of CGST, SGST, cess, and not exceeding Rs. 40 crore in respect of IGST)

Tax/ Cess < total >
  (c) Predeposit in case of subsection (3) of section 129 Penalty < total >";

(b) Details of payment of admitted amount and pre-deposit (pre- deposit 10% of disputed tax and cess but not exceeding Rs. 20 crore each in respect of CGST, SGST, cess, and not exceeding Rs. 40 crore in respect of IGST)

Sr. No. Description Tax payable Paid through Cash/ Credit Ledger Debit entry no. Amount of tax paid
Central tax State/UT tax Integrated tax CESS
1 2 3 4 5 6 7 8 9
1. Integrated tax   Cash Ledger          
Credit Ledger          
2. Central tax   Cash Ledger      
Credit Ledger          
3. State/UT tax   Cash Ledger          
Credit Ledger          
4. CESS   Cash Ledger          
Credit Ledger          

(c) Interest, penalty, late fee and any other amount payable and paid

Sr. No . Description

Amount payable

 Debit entry no. Amount paid
Integrated tax Central tax State/UT tax CESS Integrated tax Central tax State/UT tax CESS
1 2 3 4 5 6 7 8 9 10 11”;
1. Interest                  
2. Penalty                  
3. Late fee                  
4. Others (specify)                  

16. Whether appeal is being filed after the prescribed period - Yes / No

17. If ‘Yes’ in item 17 -

    (a) Period of delay -

    (b) Reasons for delay -

18. Place of supply wise details of the integrated tax paid (admitted amount only) mentioned in the Table in sub-clause (a) of clause 15 (item (a)), if any

Place of Supply (Name of State/UT) Demand  Tax  Interest  Penalty  Other Total  
1 2 3 4 5 6  7”
  Admitted amount [in the Table in sub-clause (a) of clause 15 (item (a))]          
             

Verification

□ I, < _________________________ >, hereby solemnly affirm and declare that the information given hereinabove is true and correct to the best of my knowledge and belief and nothing has been concealed therefrom.

Place:

<Signature>

Date:

Name of the Applicant: